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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RFOI IFST# <br /> lure 'F/-\ 2S°I eS\(2 0q�1 <br /> OWNER/OPERATOR l/� n <br /> ,^ , <br /> " Q ' / l CHECK If BILLING ADDRESS <br /> FACILITY NAME—ft 1 4 al- P40" a k? // <br /> -In /r <br /> SITE <br /> 6 L bs c�(,k2 Y �aC'&-0 e�,� �d J�DPC Ste-I C� <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING DRESS (If Different from Site Address) yy,JJ//� Pi <br /> 96 )--6 KoN o ) Q �(�e�`�H8lreet Number C' Street Name <br /> CITY 0 C `Tv �/ STATE C� ZIP <br /> PHONE#1 ` / / EXT. APN# LAND USE APPLICATION# C� <br /> PHONE ill EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> � / n ✓1r J � �� Gl CHECK If BILLING ADDRESS <br /> BUSINESS NAME `�/I (�` �l•,/ 1 ��� � 1 PHONE# EXT. <br /> HOME or MAI G ADDR SS / FAX# <br /> CITY W')Ci ` STATE�/1 ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. l,J <br /> APPLICANT'S SIGNATURE: k �LU44f—<� ' DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS provi %,Lne or <br /> my representative. %1r <br /> TYPE OF SERVICE REQUESTED: O C DI�C6-\A <br /> COMMENTS: GVQW'� 4 n vja� <br /> y���FAq EH q�N <br /> RT,yENT <br /> ACCEPTED BY: 1 pn n 1 1 / EMPLOYEE#: DATE: <br /> ASSIGNED TO: t7 'tel Y • EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l� PIE: <br /> g <br /> Fee Amount: `'r �9 �= Amount Paid Payment Date I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />